IN THE DISTRICT COURT OF SEDGWICK COUNTY, KANSAS ____________________, Plaintiff vs. ____________________, Defendant Case No. _______________ UNIFORM CHILD CUSTODY JURISDICTION AND ENFORCEMENT ACT (UCCJEA) AFFIDAVIT (K.S.A. 60-3101 et seq.) I, (full legal name) that the following statements are true: , of lawful age, being first duly sworn, certify 1. The names and dates of birth of the children now under eighteen years of age and subject to this proceeding are: a._____________________________ (child's name), was born in _________ (month) _________ (year). b._____________________________ (child's name), was born in _________ (month) _________ (year). c._____________________________ (child's name), was born in _________ (month) _________ (year). d._____________________________ (child's name), was born in _________ (month) _________ (year). 2. The child(ren) now live with:_______________________________________ (name of adult) at _____________________________________________________________________ (Street address), ________________________________________ (city), ______________ (state) and have lived at this place since ___________________________ (date). *If you are the petitioner and have requested that the court keep your address confidential pursuant to K.S.A. 60-3104(e), you should write "confidential" in any space that would require you to enter the address where you are currently living. 3. All the children lived together at the following addresses with the adults listed during the past five years. If the children lived at different addresses from each other, complete this information for each child separately using the spaces provided on page four. Make additional copies of page four as needed. Name and Relationship of Adult(s) From Date Until Date City, State Living with Child, and Adult(s) Present Address 05/27/09 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com *If you are the petitioner and have requested that the court keep your address confidential pursuant to K.S.A. 60-3104(e), you should write "confidential" in any space that would require you to enter the address where you are currently living. 4. I have have not been involved in a court case involving the custody or visitation of the child(ren). The following court cases are on file about the child(ren): Type of Case Court, City and State Case Number Last Order Date have do not have information concerning ANY OTHER proceeding that could affect 5. I the current proceeding, including but not limited to proceedings for enforcement and proceedings relating to domestic violence, protective orders, termination of parental rights and adoption. The following court cases are on file and could affect the current proceedings: Type of Case Court, City and State Case Number Last Order Date 05/27/09 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com PS-2990 6. The following named persons not a party to this proceeding have physical custody or claim to None have custody or visitation rights with respect to any child subject to this proceeding: Name Address, City and State Check the box that applies Has Physical Custody Claims Custody Rights Claims Visitation Rights Has Physical Custody Claims Custody Rights Claims Visitation Rights Has Physical Custody Claims Custody Rights Claims Visitation Rights Has Physical Custody Claims Custody Rights Claims Visitation Rights Has Physical Custody Claims Custody Rights Claims Visitation Rights 7. I acknowledge that I have a continuing duty to inform the court of proceeding(s) in this or any other state that could affect the current proceeding. VERIFICATION STATE OF ____________________ ) ) ss: COUNTY OF __________________ ) I swear or affirm that the statements made in this Affidavit are true and correct to the best of my knowledge and belief and that I am the person filing this affidavit. __________________________________________ Plaintiff's signature SUBSCRIBED AND SWORN to before me, a Notary Public, this ______ day of _______________________________ 20 . __________________________________________ Notary Public My Appointment Expires: ___________________ 05/27/09 3 of 4 American LegalNet, Inc. www.FormsWorkFlow.com PS-2990 (Make as many copies of this page as necessary.) THE FOLLOWING INFORMATION IS TRUE: (Child's Full Legal Name) address(es) with the adult(s) listed during the past five years: From Date Until Date City, State , lived at the following Name and Relationship of Adult(s) Living with Child, and Adult(s) Present Address *If you are the petitioner and have requested that the court keep your address confidential pursuant to K.S.A. 60-3104(e), you should write "confidential" in any space that would require you to enter the address where you are currently living. THE FOLLOWING INFORMATION IS TRUE: (Child's Full Legal Name) address(es) with the adult(s) listed during the past five years: From Date Until Date City, State , lived at the following Name and Relationship of Adult(s) Living with Child, and Adult(s) Present Address *If you are the petitioner and have requested that the court keep your address confidential pursuant to K.S.A. 60-3104(e), you should write "confidential" in any space that would require you to enter the address where you are currently living. 05/27/09 4 of 4 American LegalNet, Inc. www.FormsWorkFlow.com PS-2990